North Wales Cancer Network



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|North Wales Cancer Network |

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|North Wales |

|Haematological Cancers |

|Multidisciplinary Team (MDT) |

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|Operational Policy |

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|DRAFT 5 – January 2007 |

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|Policy agreed . . . . . . . . . . . . . . . . . . . . . |

|Policy to be reviewed by . . . . . . . . . . . . |

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CONTENTS

1.0 INTRODUCTION 4

2.0 SCOPE OF THE SERVICE 4

2.1 RESOURCES AVAILABLE AT EACH SITE 5

3.0 MDT STRUCTURE AND IMPLEMENTATION 6

3.1 NORTH WALES MDT MODEL 6

3.2 CORE MDT MEMBERS 6

3.3 ROLE OF THE CORE MDT 7

3.4 CORE MDT LEAD CLINICIAN 7

3.5 LOCAL CLINICAL TEAM MEMBERS 7

3.6 ROLE OF THE LOCAL CLINICAL TEAMS 9

3.7 LOCAL CLINICAL TEAM LEAD CLINICIAN 10

4.0 ACCESSING THE SERVICE 10

4.1 URGENT ‘SUSPECTED CANCER’ GP REFERRALS 10

4.2 OTHER REFERRALS 10

4.3 EMERGENCY ACCESS TO CLINICAL TEAM 10

4.4 WAITING TIMES 10

5.0 TREATMENT PLANNING DECISIONS 11

5.1 YSBYTY GWYNEDD 11

5.2 YSBYTY GLAN CLWYD 11

5.3 YSBYTY MAELOR 11

5.4 JOINT/COMPLEX MEETINGS 11

6.0 ACCESS TO OTHER SERVICES 12

6.1 PSYCHOLOGICAL SUPPORT 12

6.2 FERTILITY SERVICES 12

6.3 OTHER SUPPORT SERVICES 12

6.4 PALLIATIVE CARE 12

7.0 PATIENT PATHWAYS 12

8.0 CLINICAL GUIDELINES AND POLICIES 13

9.0 RISK MANAGEMENT 13

10.0 COMMUNICATION 13

10.1 COMMUNICATION BETWEEN TEAM MEMBERS 13

10.2 COMMUNICATION BETWEEN MDT AND PATIENT/CARER 14

10.3 COMMUNICATION SKILLS TRAINING 14

10.4 PATIENT WRITTEN INFORMATION 14

10.5 COMMUNICATION WITH GPs 14

11.0 DATA COLLECTION AND INFORMATION 14

12.0 AUDIT 15

13.0 CLINICAL TRIALS 15

14.0 NEW DRUGS 15

15.0 ONGOING EDUCATION 15

16.0 SERVICE IMPROVEMENT 15

17.0 AGREEMENT TO OPERATIONAL POLICY 16

Appendix 1 core mdt Terms of reference 17

Appendix 2 core mdt lead clinician job description 19

1.0 INTRODUCTION

This operational policy details the scope and organisation of services offered by the North Wales Haematological Cancers MDT. It sets out the agreed standards and processes to which all members of the MDT should work in order to ensure the delivery of high quality patient focused care.

The policy has been developed in accordance with national guidelines on the delivery of haematological cancer services, including NICE guidance on Improving Outcomes in Haematological Cancers (2003), the WAG National Standards for Haematological Cancer Services (2005) and JACIE Standards for Haematopoietic Progenitor Cell Collection, Processing and Transplantation (2005).

The objectives of this policy are to:

• Provide a detailed description of the foundations that support the single MDT model adopted in North Wales

• Describe the operational policy by which MDT members should function

• Provide an indication to policy makers, commissioners and other stakeholders of how the service is configured and how it functions

• Establish a framework for the future assessment of the service

This policy will be reviewed annually by the North Wales Haematological Cancers MDT and updated as appropriate.

2.0 SCOPE OF THE SERVICE

The North Wales Haematological Cancers MDT provides care to a total population of approximately 665,000 (2001 census). The MDT acts as a single team with services based on three sites:

• Ysbyty Gwynedd, Bangor, part of North West Wales NHS Trust

• Ysbyty Glan Clwyd, Bodelwyddan, part of Conwy and Denbighshire NHS Trust

• Ysbyty Maelor, Wrexham, part of North East Wales NHS Trust

The MDT manages adults with leukaemia, lymphomas and myeloma. All children presenting with a haematological malignancy are referred to the specialist service at Alder Hey Hospital in Liverpool.

The MDT offers treatment up to BCSH level 3 ie up to and including high dose therapy with autologous transplantation. Patients requiring level 4 services (ie allogeneic transplantation) are referred to hospitals outside the North Wales Cancer Network, dependent upon the exact nature of the disease and treatment required.

The stem cell harvest service is based at Ysbyty Gwynedd with subsequent re-infusion taking place either at Ysbyty Gwynedd or Ysbyty Glan Clwyd. Wrexham patients are referred to the Christie Hospital in Manchester for stem cell transplantation; the MDT is working towards the repatriation of this work to North Wales in 2007/08. The service at Ysbyty Gwynedd currently performs an average of 13 autologous transplants p.a. and is preparing for JACIE accreditation in 2007/08.

Radiotherapy is provided at the North Wales Cancer Treatment Centre at Ysbyty Glan Clwyd. In addition, Wrexham lymphoma patients requiring therapeutic radiotherapy are referred to the Christie Hospital in Manchester and all patients requiring total body irradiation prior to allogeneic transplantation are referred to the hospital undertaking the transplantation.

Diagnostic services are available at all three sites. In addition the MDT has access to specialist pathology services via the All Wales Lymphoma Review Panel and the cytogenetics service in Cardiff. Patients requiring PET-CT scanning are referred to Mount Vernon Hospital, Watford, in line with the Health Commission Wales service level agreement.

2.1 RESOURCES AVAILABLE AT EACH SITE

YSBYTY GWYNEDD

|Inpatient facilities |Alaw Ward - an 18 bedded haematology, oncology and palliative care ward; 8 single rooms, of which 6 are |

| |ensuite |

|Day care facilities |Alaw Day Unit - a dedicated haematology/oncology day case and outpatient unit; 5 beds and 5 chairs for day|

| |case treatments |

|Support services |All laboratories on site; on-site CT, MRI, bronchoscopy, ITU and HDU |

|Medical staff |4 consultant haematologists (inc. 2 part-time); 1 full-time and 2 part-time Staff Grades; 1 Associate |

| |Specialist in Oncology for stem cell work |

|Nursing staff |1 specialist nurse in haematology; chemotherapy and haematology trained nurses on Alaw Unit (inc. venous |

| |access) |

|Pharmacy |On-site pharmacy using open laminar flow system; Trust developing business case for on site aseptic unit. |

| |Lead pharmacist for oncology |

YSBYTY GLAN CLWYD

|Inpatient facilities |Enfys Ward - a 20 bedded haematology and oncology ward within the North Wales Cancer Treatment Centre |

| |(NWCTC); 8 single rooms with ensuite including 3 with HEPA filtration for stem cell re-infusion. |

|Day care facilities |Heulwen Day Care Unit – a dedicated haematology/oncology treatment unit within the NWCTC; 16 chairs/beds |

| |for day case treatments |

|Support services |All laboratories on site; on-site CT, MRI, bronchoscopy, ITU and HDU |

|Medical staff |4 consultant haematologists (of whom 3 are full-time haemato-oncologists); 1 Staff Grade and 1 ST1 |

|Nursing staff |1 haematology nurse practitioner; chemotherapy and haematology trained nurses on Enfys and Heulwen (inc |

| |venous access) |

|Pharmacy |On-site aseptic unit; dedicated pharmacist for haematology |

YSBYTY MAELOR

|Inpatient facilities |Access to 6 inpatient beds on Mason Ward (medical ward) with scope for more if required; 5 single rooms |

| |inc. 2 en-suite |

|Day care facilities |Shooting Star Unit - a purpose built, dedicated haematology/oncology day case and outpatient unit; 5 beds |

| |and 6 chairs for day treatments |

|Support services |All laboratories on site; on-site CT, MRI, bronchoscopy and ITU |

|Medical staff |2 consultant haematologists; 1 Associate Specialist and 0.5wte Staff Grade |

|Nursing staff |1 haematology clinical nurse specialist; chemotherapy and haematology trained nurses on Mason Ward and the|

| |Shooting Star unit (inc. venous access) |

|Pharmacy |On-site aseptic unit; dedicated pharmacist for haematology |

3.0 MDT STRUCTURE AND IMPLEMENTATION

The North Wales Haematological Cancers MDT recognises that a multi-disciplinary approach is essential to the management of haematological cancer patients.

MDT working ensures the provision of high quality care through the sharing of knowledge and expertise. Both policy development and individual patient treatment planning decisions are improved through review, discussion and agreement by experienced clinicians from a range of specialties.

3.1 NORTH WALES MDT MODEL

The North Wales Haematological Cancers MDT has adopted a model whereby the service is overseen by a core North Wales MDT with care delivered to patients on three different sites; this ensures access to a high quality local service for the entire North Wales population.

The North Wales MDT membership therefore reflects two levels of involvement:

1. Core MDT members – these members are responsible for the overall running of the North Wales haematological cancers service by defining its operational policy

2. Local clinical team members – these members are the local arm of the North Wales MDT and are responsible for local service delivery in line with the overarching MDT operational policy

3.2 CORE MDT MEMBERS

The core MDT is representative of each core discipline and each site providing treatment as part of the North Wales Haematological Cancers MDT. Additional members of the clinical teams may be invited to attend core team meetings as required.

|Name |Title |Location |

|Dr D Edwards |Consultant Haematologist and lead clinician |Ysbyty Gwynedd |

|Dr J R C Seale |Consultant Haematologist |Ysbyty Gwynedd |

|Dr C F Hoyle |Consultant Haematologist |Ysbyty Glan Clwyd |

|Dr M J Goodrick |Consultant Haematologist |Ysbyty Glan Clwyd |

|Dr E Heartin |Consultant Haematologist |Ysbyty Glan Clwyd |

|Dr D Watson |Consultant Haematologist |Ysbyty Maelor |

|Dr J Duguid |Consultant Haematologist |Ysbyty Maelor |

|To be agreed |Pathologist (local/Lymphoma Panel rep) | |

|Dr A Nethersell |Consultant Clinical Oncologist |Ysbyty Glan Clwyd |

|Dr D J Widdowson |Consultant Radiologist |Ysbyty Glan Clwyd |

|Linda Jones |Specialist Nurse in Haematology |Ysbyty Gwynedd |

|Steph Jackson |Haematology Nurse Practitioner |Ysbyty Glan Clwyd |

|Jayne Samuels |Clinical Nurse Specialist, Haematology |Ysbyty Maelor |

|To be agreed |Ward sisters | |

|To be agreed |Palliative care specialist | |

|Nicola Andrews |Data lead |Ysbyty Glan Clwyd |

|Damian Heron* |Director |NWCN |

|Caroline Williams* |Project lead |NWCN |

|Gillian Evans* |User advisor |NWCN |

* where appropriate

3.3 ROLE OF THE CORE MDT

The core MDT meets regularly (as a minimum quarterly).

The role of the North Wales Haematological Cancers core MDT is to:

• Agree an operational policy for the delivery of haematological cancer services across North Wales based on current national guidance and accepted best practice

• Ensure the operational policy is implemented effectively on all three sites and reviewed and updated annually

• Agree referral and clinical guidelines for haematological malignancies in North Wales

• Agree optimum patient pathways for each disease type

• Ensure service improvement is embedded in local teams and initiate MDT wide initiatives

• Agree a minimum data set and analyse clinical data capture, performance and outcomes

• Agree and implement an annual audit programme

• Address any MDT wide governance or operational issues raised by the local clinical teams

• Identify core MDT training needs and agree an ongoing educational programme

• Agree a list of clinical trials and prepare any submissions for clinical trials

• Prepare any submissions for new drugs

• Agree an annual work plan

• Act as the Network advisory group for haematological malignancies, advising on service provision and making recommendations for service development/reconfiguration

Full terms of reference are attached as Appendix 1.

3.4 CORE MDT LEAD CLINICIAN

The core MDT lead clinician has responsibility for the development and overall running of the North Wales Haematological Cancers MDT, in particular:

• To agree the membership and role of the core MDT and ensure it meets at least quarterly

• To ensure the core MDT agrees an operational policy and clinical guidelines for the optimum management of haematological cancer patients based on accepted best practice.

• To ensure the operational policy is reviewed and updated annually

• To ensure clinical guidelines and patient pathways are reviewed and updated regularly

• To ensure that care is delivered on all three sites in line with the agreed operational policy and clinical guidelines

• To ensure the MDT fulfils its full role as defined in its terms of reference

• To agree an annual work plan for the core MDT

• To attend both Trust and Network cancer meetings and provide expert advice on the tumour site as appropriate, including fulfilling the role as the designated Network Board member

The lead clinician’s duties are included in his/her job plan.

A full job description is attached as Appendix 2.

3.5 LOCAL CLINICAL TEAM MEMBERS

The local clinical teams comprise members of each core discipline required to provide treatment as part of the North Wales Haematological Cancers MDT. In addition each has extended members who offer advice to the team as required.

YSBYTY GWYNEDD

|Name |Title |Telephone |Cover |

|Dr J Seale |Consultant Haematologist; lead clinician |01248 384370 |Internal cross-cover |

|Dr D Edwards |Cons Haematologist; transplant lead |01248 384369 | |

|Dr H Korn |Locum Cons Haematologist (part-time) |01248 384384 x5227 | |

|Dr H Parry |Locum Cons Haematologist (part-time) NB Leaves March ‘07 |01248 384369 | |

|Dr E Mitchell |Staff Grade Haematologist (part-time) |01248 384369 | |

|Dr S Griffiths |Staff Grade Haematologist (part-time) |01248 384369 | |

|Dr I Tahan |Staff Grade Haematologist |01248 384369 | |

|Dr T Caslin |Consultant Histopathologist |01248 394719 |Internal cross-cover |

|Dr M Lord |Consultant Histopathologist |01248 394719 | |

|Dr S Andrew |Consultant Histopathologist |01248 394719 | |

|Dr T Nethersall |Consultant Clinical Oncologist, NWCTC |01745 445157 |No cover |

|Dr R Williams |Associate Specialist, Oncology (haem) |01248 384150 |No cover |

|Dr S Wenham |Consultant Radiologist |01248 384690 |No cover |

|Linda Jones |Specialist Nurse in Haematology |01248 384384 x5171 |Internal cross-cover |

|Manon Jones |Senior Nurse, Alaw Unit |01248 384945 | |

|Jackie Jones |Ward Sister, Alaw Ward |01248 384945 | |

|Laura Edge |Ward Sister, Alaw Day Unit |01248 384008 | |

|Elaine Wain |Deputy Sister, Alaw Day Unit |01248 384008 | |

|Dr A Fowell |Macmillan Consultant in Palliative Care |01248 384384 x5142 |L Roberts |

|Tania Seale |Haematology Research Nurse |01248 384994 |Internal cross-cover |

|Alice Thomas |Haematology Research Nurse |01248 384995 | |

|Mark Hankey |Data co-ordinator |01248 384384 x5191 |Sec team |

|Plus the following extended team members: | | |

|Dr S Darcey |Consultant Microbiologist |01248 384367 | |

|M Hughes |Pharmacist |01248 384140 | |

YSBYTY GLAN CLWYD

|Name |Title |Telephone |Cover |

|Dr C Hoyle |Consultant Haematologist; lead clinician |01745 534881 |Internal cross-cover |

|Dr M Goodrick |Consultant Haematologist |01745 536739 | |

|Dr E Heartin |Consultant Haematologist |01745 534377 | |

|Dr M Hassan |Staff Grade Haematologist |01745 534881 | |

|Dr M Atkinson |Consultant Histopathologist |01745 534064 |Dr Giles |

|Dr T Nethersell |Consultant Clinical Oncologist |01745 445157 |Dr Azam |

|Dr Widdowson |Consultant Radiologist |01745 534115 |Internal |

| | | |cross-cover/SpR |

|Dr P Travis |Consultant Radiologist |01745 534516 | |

|Steph Jackson |Haematology Nurse Practitioner |01745 445272 |Internal cross-cover |

|Gwyneth Davis |Clinical Trials Nurse |01745 445211 | |

|Nerys Wilkes |Sister, Enfys Ward |01745 445251 | |

|Dr C Usborne |Consultant in Palliative Care |01745 445909 |Yvonne Rose |

|Sue Randles |MDT co-ordinator |01745 445170 |Anne Hughes |

|Plus the following extended team members: | | |

|Dr D Edwards |Transplant Director, Ysbyty Gwynedd |01248 384369 | |

|Dr N Looker |Consultant Microbiologist |01745 534356 | |

|Dr P Manion |Consultant Microbiologist |01745 534708 | |

|Dr C Bell |Consultant Anaesthetist |01745 534650 | |

|H Flint |Clinical Lead Pharmacist, Haematology |01745 535242 | |

|C Wood |Radiotherapist |01745 445130 | |

|C Vickering |Dietician |01745 445239 | |

YSBYTY MAELOR, WREXHAM

|Name |Title |Telephone |Cover |

|Dr D Watson |Consultant Haematologist; lead clinician |01978 725100 |Internal cross-cover |

|Dr J Duguid |Consultant Haematologist |01978 725866 | |

|Dr L DeSoysa |Associate Specialist, Haematology |01978 725081 | |

|Dr P Smith |Staff Grade, Haematology/Oncology |01978 727603 | |

|Dr R Williams |Consultant Histopathologist |01978 725610 |Internal cross-cover |

|Dr A Burdge |Consultant Histopathologist |01978 725079 | |

|Dr K Pradeep |Consultant Histopathologist |01978 725611 | |

|Dr A Al-Samarraie |Consultant Clinical Oncologist, NWCTC |01745 445158 |No cover |

|Dr M Elias |Consultant Radiologist |01978 727800 |Internal cross-cover |

|Dr J Klafkowski |Consultant Radiologist |01978 725493 | |

|Jayne Samuels |Clinical Nurse Specialist, Haematology |01978 727130 |Internal cross-cover/Wenna|

| | | |Hammond |

|Anne-Marie Humphreys |Sister, Shooting Star Day Unit |01978 727603 | |

|Sr T Vipond |Ward sister, Mason Ward |01978 725443 | |

|Dr M Makin |Consultant in Palliative Care |01978 290919 |Macmillan CNS |

|Sandra Davies |MDT co-ordinator/patient tracker |01978 725199 |Other cancer co-ordinator |

|Plus the following extended team members: | | |

|Dr E Liailopoulou |Transplant Director, Christie Hospital |0161 446 8488 | |

|Dr C Cefai |Consultant Microbiologist |01978 725861 | |

|A Ellis-Jones |Pharmacist |01978 725959 | |

In addition the MDT has access as required to the following specialities on each site: dietetics, orthopaedic surgery, dermatology, gastroenterology, ENT, interventional radiology, renal medicine, social work, physiotherapy, occupational therapy, psychology and counselling.

3.6 ROLE OF THE LOCAL CLINICAL TEAMS

The role of local clinical teams is to:

• Deliver care in line with the agreed MDT operational policy

• Review all patients, establish and record a diagnosis and agree a treatment plan

• Discuss responses to treatment during and at the end of therapy and agree any necessary changes in management

• Consider all facets of individual patient’s needs including their psychological needs and liaise with primary care, palliative care, elderly services, voluntary organisations as appropriate

• Identify requirements for staff and facilities for the treatment it offers

• Ensure adequate information, advice and support is given to patients and carers

• Ensure GPs are given prompt and full information on patient management and contact details of relevant clinical team members

• Record the minimum data set for all haematological malignancies

• Identify members’ training needs and ensure these are met

• Participate in clinical trials and research

• Collaborate in MDT audit

• Lead local service improvement initiatives and participate in MDT wide initiatives

• Review any local clinical governance issues including untoward incidents ensuring appropriate action is taken

3.7 LOCAL CLINICAL TEAM LEAD CLINICIAN

Each of the three sites where care is delivered has a lead clinician who is also a member of the core MDT. He/she is responsible for ensuring that:

• The delivery of care at a local level is compliant with the policies, guidelines and protocols adopted by the North Wales MDT

• The local team at all levels of involvement are familiar and compliant with the policies, guidelines and protocols adopted by the North Wales MDT

• Local clinical governance issues are addressed

• Any conflict between local requirements and that of the MDT are raised with the MDT lead and the employing Trust is informed of the need to do so.

4.0 ACCESSING THE SERVICE

4.1 URGENT ‘SUSPECTED CANCER’ GP REFERRALS

All patients meeting the criteria set out in the NICE ‘Referral for suspected cancer’ guidelines (.uk) should be referred to the appropriate local clinical haematological cancers team without delay, as set out in each Trust’s Directory of Cancer Services. This Directory is available on each Trust intranet site and is circulated to local GP practices.

All referrals are reviewed by a consultant within 24 hours and if deemed to be appropriate, the patient will be seen within a maximum of 10 working days. If the referral is inappropriate, an alternative course of action is offered eg a routine appointment.

4.2 OTHER REFERRALS

Many patients with haematological malignancies, in particular lymphomas, are referred initially to other specialty teams. As soon as a haematological malignancy is diagnosed, a copy of the pathology report should be sent to the local haematological cancers team; in addition any abnormal electropherysis result should be copied by the biochemistry laboratory to the haematology department to follow-up.

4.3 EMERGENCY ACCESS TO CLINICAL TEAM

All patients and their GPs should be given details of how to access members of the local clinical team in an emergency. North Wales triage standards are currently being developed and will be implemented by each team.

4.4 WAITING TIMES

All patients diagnosed with a haematological malignancy will, where appropriate, start definitive treatment within national waiting times targets. In reality treatment usually begins much earlier than this in line with clinical need.

5.0 TREATMENT PLANNING DECISIONS

All patients with haematological cancers should be managed by a member of the North Wales Haematological Cancers MDT. Any patient with a haematological malignancy initially presenting to another speciality should be referred to the Haematological Cancers MDT without delay.

All patients should be reviewed by their local clinical team and multi-disciplinary treatment planning decisions made in line with agreed MDT clinical guidelines and protocols through daily ward rounds and weekly clinical meetings held on each site.

5.1 YSBYTY GWYNEDD

• All patients are reviewed on daily consultant-led ward rounds

• A clinical team meeting is held every Wednesday morning to review all new malignancies, pre-malignancies and other complex cases; the outcomes are recorded on an MDT proforma. This meeting is attended by all members of the local clinical team (see section 3.5) with the exception of the histopathologists and consultant oncologist

• A pathology meeting is held on alternate Mondays with the haematologists and pathologists

5.2 YSBYTY GLAN CLWYD

• All patients are reviewed on daily consultant-led ward rounds

• A clinical team meeting is held every Friday to discuss all new cancer patients; a list of patients to be discussed is sent out in advance of the meeting, based on new diagnoses made in clinics or via emergency admissions and any additional cases highlighted by histology. The meeting is recorded with minutes circulated to all members of the team; a register of attendance is kept. This meeting is attended by all members of the core local clinical team (see section 3.5) with the exception of the histopathologist, palliative care consultant and ward sister

• A pathology meeting is held every Tuesday with the haematologists and histopathologist

5.3 YSBYTY MAELOR

• All patients are reviewed on daily consultant-led ward rounds

• A clinical team meeting is held every Monday morning to review all patients to be treated that week with the medical team, day unit nursing team, pharmacist and co-ordinator/tracker

• A radiology meeting is held on the first and third Friday of each month to review old and new patients; the medical team, radiologists, CNS, day unit nursing staff attend this meeting

• Discussions are held with the histopathologist, oncologist and palliative care team on individual cases as required

5.4 JOINT/COMPLEX MEETINGS

• Stem cell meetings are held at Ysbyty Gwynedd on the first Friday of every month to review all stem cell transplant patients. The team from Ysbyty Glan Clwyd attend every other month. The Wrexham team will join this meeting when their stem cell transplantation work is repatriated to North Wales

• Where individual complex cases arise, the North Wales Haematology Cancers MDT is available via email, telephone, video-conferencing or the case may be added to the agenda of an existing meeting eg the Blood Club or MDT meeting. Alternatively, members of the MDT may contact nationally recognised experts for advice prior to the local clinical team meeting in order to ensure the delivery of best possible clinical care.

6.0 ACCESS TO OTHER SERVICES

6.1 PSYCHOLOGICAL SUPPORT

Psychological support is offered by the clinical nurse specialists/nurse practitioners in the local clinical teams who also provide patients with details of any local support groups. Where specialist support is required patients from Ysbyty Glan Clwyd and Ysbyty Wrexham can be referred to the psychology support team based at Ysbyty Glan Clwyd. Patients at Ysbyty Gwynedd can access specialist courses in stress reduction (Mindfulness). The teams can also access their local psychiatric liaison services if required.

6.2 FERTILITY SERVICES

The MDT supports patients who wish to access fertility services prior to treatment. It is the agreed policy of the MDT that male patients should be referred to St Mary’s in Manchester and female patients should be referred to the specialist gynaecology service at the Liverpool Women’s Hospital. Ysbyty Gwynedd currently provides a sperm storage service but this is under review following the introduction of more stringent legislation in this area and it is likely Bangor patients will soon be referred to St Mary’s in Manchester in line with MDT policy.

6.3 OTHER SUPPORT SERVICES

The MDT has access to dieticians, physiotherapists, OTs and benefits advisors at each site.

6.4 PALLIATIVE CARE

The transition from active treatment to palliative care is handled sensitively in accordance with the patient’s individual needs and wishes. Local clinical teams have access to specialist palliative care where appropriate via the individuals listed in section 3.5 above. Each local clinical team follows its Trust’s agreed end of life pathway.

7.0 PATIENT PATHWAYS

The North Wales Haematological Cancers MDT has agreed to adopt the All Wales patient pathways for haematological cancers where they exist. The lymphoma pathway has been published and is included as Appendix (need to add); work is ongoing to develop All Wales pathways for CLL and AML.

For disease types where there is no All Wales pathway, the MDT will work to develop a local agreed pathway.

8.0 CLINICAL GUIDELINES AND POLICIES

All patients must be treated according to agreed clinical guidelines or as part of a formal clinical trial.

The North Wales Haematological Cancers MDT has agreed the following clinical guidelines:

• The British Committee for Standardisation in Haematology (BCSH) Guidelines– see

• The North West Region Haematology Guidelines – see nwhaems.co.uk

• The Myeloma Forum Guidelines – see .uk

• The CLL Forum Guidelines– see

(Can these be pulled together and do they include imaging and follow-up?)

All treatment should also be conducted in accordance with the following Network wide policies:

• The North Wales Cancer Network Cytotoxic Chemotherapy Policy 2006

• Chemotherapy protocols for each agreed regimen; these will be collated in the next Network Formulary

• The North Wales triage guidelines (when agreed)

In addition local clinical teams should deliver care in line with local Trust policies on:

• chemotherapy administration (including intrathecal chemotherapy)

• infection prevention and control

• the use of all medical devices

• management of side effects, anaphylactic shock etc

• risk management and incident reporting

These policies and protocols are available on individual Trust intranet sites.

9.0 RISK MANAGEMENT

All risk management issues and clinical incidents should be addressed by the relevant local clinical team in line with their Trust policy on risk management and incident reporting. Any necessary action should be taken by the local clinical team and the lessons learnt shared with the core MDT.

Any risk management issue involving the whole MDT should be raised with the core MDT by the Trust identifying the issue and dealt with according to their local policy.

10.0 COMMUNICATION

10.1 COMMUNICATION BETWEEN TEAM MEMBERS

There is regular communication between on site team members via daily ward rounds and weekly clinical meetings. Where treatment planning decisions are required between these events, telephone and email communication should be used.

Members of the North Wales Haematological Cancers MDT meet regularly at quarterly MDT meetings, audit and educational meetings. In addition there is regular telephone and email communication between all members of the MDT.

10.2 COMMUNICATION BETWEEN MDT AND PATIENT/CARER

All patients and carers should be given details of how to contact members of the local clinical team when they are given their diagnosis; this may be the contact details of the consultant and/or the clinical nurse specialist.

Patients should be encouraged to bring a family member or friend with them to any consultation where important news is likely to be given. Such consultations should be held in a private room with a nurse present where possible who can then offer further support to the patient. All treatment options should be explained to patients who are then given adequate time to consider their options and make a decision.

10.3 COMMUNICATION SKILLS TRAINING

Communication skills training is available to all members of the MDT involved in direct patient care. All members of the MDT who are likely to give bad news should be encouraged to attend such training.

10.4 PATIENT WRITTEN INFORMATION

Written patient information should be offered to all patients by their consultant, clinical nurse specialist, trials nurse and/or day case senior nurses; senior nurses should also ensure such information is available in ward and outpatient areas.

The North Wales wide patient information folder should be given to all new patients with local information and national leaflets added as appropriate to the individual patient. This information will include leaflets from BACUP, LRF and Macmillan, clinical trials information sheets and local information on MDT arrangements and support groups.

10.5 COMMUNICATION WITH GPs

Following a diagnosis of haematological malignancy, the consultant should write to the patient’s GP informing them of the diagnosis and outline treatment plan.

11.0 DATA COLLECTION AND INFORMATION

The Cancer Network Information System Cymru (CaNISC) does not yet have an agreed minimum data set for haematological malignancies. However all sites within the MDT enter basic demographic and clinical data on haematological malignancies onto CaNISC and will complete the haematological dataset when agreed.

Each hospital submits Patient Episode Database for Wales data based on clinical coding information.

12.0 AUDIT

The MDT participates in all Wales clinical audits as specified by CSCG All Wales Haematological Cancer Steering Group.

In addition, the MDT audit group agrees an annual audit plan of two or three network wide audits per year including audits of practice against agreed clinical guidelines. The MDT is currently undertaking an audit of new DLBCL diagnoses and will then agree its audit plan for the forthcoming year.

13.0 CLINICAL TRIALS

The MDT will review the national list of clinical trials once available and agree which trials it will take part in.

All eligible patients should be given the opportunity to enter an agreed clinical trial. At present this does not occur at Wrexham due to a lack of resources. This issue will be taken forward by the MDT.

14.0 NEW DRUGS

The North Wales Cancer Network is setting up a network wide drugs and therapeutics committee to consider the adoption of new drugs as they appear. The MDT will work with this committee on all new haematological drugs.

15.0 ONGOING EDUCATION

The Blood Club meets three or four times per year for a programme of education. The Blood Club includes Merseyside services.

In addition members of the MDT regularly attend North West Haematologists meetings and the British Society for Haematology, European Society for Haematology and American Society for Haematology annual meetings as well as meetings of the Myeloma Forum, CLL Forum, ALL Forum, BNLI and British Blood Transfusion Service.

Both the core MDT and local clinical teams will review their training needs and agree an educational/training programme as appropriate.

16.0 SERVICE IMPROVEMENT

Service improvement should be discussed at MDT meetings and be embedded within each local service. User involvement should be encouraged in all service improvement initiatives.

17.0 AGREEMENT TO OPERATIONAL POLICY

Signature ………………………………………………….. Date ………………………………………..

Dr David Edwards

Lead Clinician of North Wales Haematological Cancers MDT and Lead Clinician, Haematological Malignancies, Ysbyty Gwynedd

Signature ………………………………………………….. Date ………………………………………..

Dr Christine Hoyle

Lead Clinician, Haematological Malignancies, Ysbyty Glan Clwyd

Signature ………………………………………………….. Date ………………………………………..

Dr David Watson

Lead Clinician, Haematological Malignancies, Ysbyty Maelor

Appendix 1

North Wales Haematological Cancers Core Multi Disciplinary Team

Membership and Terms of Reference

1. Purpose

• The core MDT is responsible for the overall running of the North Wales haematological cancers service. It aims to achieve the best possible outcomes for patients by ensuring access to a uniformly high quality of care across North Wales. It does this by defining and monitoring the operational policy by which all clinicians providing haematological cancer services in North Wales should operate; this operational policy is based on best clinical practice and national guidance.

• The core MDT is also the main source of clinical advice to the North Wales Cancer Network Management Board on all matters relating to haematology.

2. Membership

• The membership of the core MDT includes representatives from each site providing treatment as part of the North Wales Haematological Cancers MDT:

o Ysbyty Gwynedd, Bangor, part of North West Wales NHS Trust

o Ysbyty Glan Clwyd, Bodelwyddan, part of Conwy and Denbighshire NHS Trust

o Ysbyty Maelor, Wrexham, part of North East Wales NHS Trust

• The membership includes representatives of all disciplines involved in the provision of haematology services, in line with Improving Outcomes in Haematological Cancers (NICE, 2003):

o Haematologists

o Pathologists

o Oncologists

o Radiologists

o Clinical Nurse Specialists

o Ward sisters

o Palliative care specialists

o Data co-ordinators

• In addition the Network Director, Project Lead and User advisor may be invited as required.

• The Chair must ensure there is adequate representation from each site and each staff group at the MDT meeting to ensure their full involvement.

3. Chair and Deputy Chair

The Chair and Deputy Chair roles are each for a maximum of five years’ duration. The Chair and Deputy Chair will be nominated by members of the MDT. If there are two or more people nominated, there will be a vote to decide who is elected. The Chair and Deputy Chair will both be agreed by the North Wales Cancer Network Board. The Chair and Deputy Chair will not be from the same Trust.

4. Administrative support

Administrative support will be provided.

5. Frequency of meetings

Meetings will be held at least quarterly.

6. Terms of reference

Service planning

• To act as the Network advisory group for haematological malignancies, advising on service provision and making recommendations for service improvement/development/reconfiguration

• To advise the Network on the implications of national policy issues as they arise

• To agree an operational policy for the delivery of haematological cancer services across North Wales based on current national guidance and accepted best clinical practice. To review and update this policy annually

• To agree referral and clinical guidelines for haematological malignancies. To review and update these guidelines annually and audit their implementation

• To agree the optimum patient pathways for each disease type and audit implementation

Service improvement and redesign

• To ensure service improvement is embedded within each local team and initiate MDT wide improvements as appropriate

• To ensure users are involved in the planning and redesign of services

Service quality monitoring

• To ensure clinical services are delivered in accordance with required national standards i.e. JACIE, WAG cancer standards and NICE Improving Outcomes Guidance.

• To ensure that the MDT operational policy is implemented effectively on all three sites

• To ensure adequate facilities and staff exist on each site to allow full implementation of this policy

• To ensure adequate processes are in place on each site to allow full multi-disciplinary involvement in treatment decisions for individual patients. Where necessary to ensure mechanisms are in place for the North Wales MDT to advise on complex individual cases

• To agree a minimum data set for haematological malignancies and ensure it is collected on all three sites; to analyse performance and outcome data and take necessary actions

• To agree and implement an annual audit programme and review the results of these audits

• To ensure services meet national performance targets and quality standards

• To address any MDT wide clinical governance concerns raised by local clinical teams

Workforce development

• To identify core MDT members’ training needs

• To agree an annual educational programme

Research and development

• To agree a list of clinical trials, prepare submissions for new trials and ensure all eligible patients are offered the opportunity of entering a clinical trial as appropriate

• To work with the Network Drugs and Therapeutics group to agree the implementation of new drugs, preparing all necessary submissions

Annual work plan

• To agree an annual work plan for the MDT

Appendix 2

North Wales Haematological Cancers Core Multi Disciplinary Team

Lead Clinician Job Description

1. JOB TITLE: Lead Clinician, North Wales Haematological Cancers Core MDT

2. ACCOUNTABLE TO: Employing Trust

3. OVERALL RESPONSIBILITY:

• To be responsible for the development and overall running of the North Wales Haematological Cancers MDT

• To ensure that a high quality service is delivered to patients under the care of the MDT

• To establish and maintain appropriate links with all three Trusts involved in the MDT and with colleagues in the North Wales Cancer Network, primary care and the All Wales Haematological Cancers Group

• To be responsible for providing professional advice within and outside the North Wales Cancer Network on the tumour site and the MDT’s services

4. KEY WORKING RELATIONSHIPS:

• Members of the core multi-disciplinary team

• Cancer and Haematology Clinical Directors of the three Trusts involved in the MDT

• Medical Directors of the three Trusts involved in the MDT

• Cancer and Haematology Directorate Managers of the three Trusts involved in the MDT

• Director, North Wales Cancer Network

• Lead Nurse, North Wales Cancer Network

• Project Co-ordinator, North Wales Cancer Network

5. SPECIFIC DUTIES:

1. To set up the North Wales Haematological Cancers Multi-Disciplinary Team in line with NICE guidance and supported by the North Wales Cancer Network

2. To agree the membership and role of the core multi-disciplinary team

3. To ensure that the core multi-disciplinary team meets at least quarterly with an agreed core membership, records of attendance, and appropriate records of issues discussed.

4. To ensure that clinical services are delivered in accordance with required national standards i.e. JACIE, WAG cancer standards and NICE Improving Outcomes Guidance.

5. To agree an MDT operational policy for the delivery of haematological cancer services across North Wales based on current national guidance and accepted best clinical practice. To ensure this policy is reviewed and updated annually.

6. To ensure that clinical services are delivered in accordance with the MDT operational policy

7. To agree with all relevant parties optimum patient pathways, referral guidelines and clinical guidelines for each disease type and ensure these guidelines are reviewed and updated annually.

8. To agree an annual audit programme and ensure its outcomes are reviewed.

9. To agree a minimum data set for haematological malignancies and ensure mechanisms are in place to collect and review this data

10. To agree a list of recognised clinical trials and ensure consistent mechanisms are in place to assess all cancer patients for eligibility into clinical trials.

11. To ensure the MDT and local clinical teams review service improvement opportunities and embed them within clinical operational practice wherever possible.

12. To identify appropriate training needs of all members of the multi-disciplinary team, and agree at regular intervals how to meet these needs.

13. To work with other members of the MDT to ensure patient and carer views of the service are taken into account when planning and delivering services.

14. To ensure any MDT wide clinical governance issues raised by local clinical teams are addressed by the core MDT

15. To agree an annual work programme for the MDT

16. To advise the North Wales Cancer Network Board on issues likely to affect the strategic development of haematological cancer services.

6. TENURE:

The post is tenable for a period of up to five years from the date of acceptance.

Signed Signed

…………………………………………………. ……………………………………………

Date: …………………………………………... Date: ……………………………………..

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